BRENCHLEY AND HORSMONDEN MEDICAL PRACTICE - NEW PATIENT QUESTIONNAIRE
Thank you for registering with our practice. As it can take some time for your medical records to be forwarded from your last practice please complete the questionnaire below.
Mr/ Mrs/ Miss/ Other: …………………………………Date of Birth: …………………………………………………
Forename: …………………………………………………..Surname: …..…………………………………………………
Occupation: …………………………………………..… … Home tel no: ……..……………………………………………
Email: ………………………………………………………….Mobile tel no: ..……………………………………………….
Medical History
Please list any significant illnesses/operations
Family History
Do you have any significant family history of illnesses in relatives eg heart disease under 60 years/strokes under 60 years/cancer and type?
Medication
If you are on repeat medication please let us have a copy of your repeat order form from your previous GP.
Allergies? ......
Height ...... Weight ......
Smoking Status- Pleasetick:For office use
I have neversmoked □1371
I am a current non-smoker □ Date of stopping?...... 137F
I am a currentsmoker □ If so how many cigarettes per day?...... 137R
If you are currently smoking and wouldlike to be put in touchwith the local smoking cessation group
pleaseask at Reception for information.8Cal
AlcoholIntake38D4
How manyunits of alcohol do you drink on average a week? ………………………………………
Pint of beer = 2 units Glass of wine (175 mls) = 2 units Spirits (single) = 1 unit
Questions / 0 / 1 / 2 / 3 / 4 / YourScoreHow often do you have a
drink thatcontainsalcohol? / Never / Monthly
or less / 2-4 times
per month / 2-3 times
per week / 4+times
per week
How many standard alcoholic
drinks do you have on atypical
daywhenyou are drinking? / 1 – 2 / 3 – 4 / 5 – 6 / 7 – 8 / 10+
How often do you have 6 or more
Standard drinks on one occasion? / Never / Lessthan
monthly / Monthly / Weekly / Daily or
almost daily?
TOTAL
Ethnicity/First language
We are nowrequired by the Department of Health to record the ethnicity and first language of our patients. Pleaseindicateyourethnicorigin. This is not compulsory, but may help withyour healthcare as somehealthproblems are more common in specificcommunities and knowingyouroriginsmay help with the early identification of some of these conditions.
Wouldyoupleaseindicatebelowwhichapplies to you:
British/mixed□Indian/British □Irish □Pakistani/British□
Other White□Bangladeshi/British □Caribbean □ Other Asian□
African □Other Black □White & Asian□Chinese □
Other mixed□Prefer not to answer□
First language: ......
Cervical Smear (if applicable) - date of last test if known………………......
CarersFor office use
Do you look aftersomeoneor doessomeone look afteryou? Yes / No* (*delete as appropriate)Is a carer: 918A
If yes, pleaseask at Reception for a Carer Registration FormHas a carer: 918F
Summary Care Record
The NHS isimproving the wayyourhealth information isstored and managedthrough the introduction of the electronicSummary Care Record (SCR). Initially a SCR willcontain key health information including allergies and currentmedicationsextractedfrom the patient’s GP record.
Do you consent to having an electronicSummary Care Record? For office use Yes / No* (*delete as appropriate) Express dissent: 9Ndo
Express consent:9Ndm
Implied consent: 9Ndl
Care Data
NHS Englandnowrequires healthcare providers (including GP practices) to share patient data with the Health & Social Care Information Centre (HSCIC). If you do not wishyour information to besharedoutside the GP practice – for anypurposeotherthan direct care – pleaseindicatehere and your record willbecodedaccordingly. Yourdecisionwill not affect the care youreceive and shouldyou change yourmindpleasenotify us and your consent statuscanbeamended. If youwouldlike more information about care.datapleaseask at Reception.
Do you consent to your patient data beingsharedotherthan for medical care? For office use
Yes / No* (*delete as appropriate)Dissent fromsecondary use
of GPpatient identifiable data: 9Nu0
Dissent fromdisclosure of
personalconfidential data by HSCIC:9Nu4
Leaving Messages
In accordance with the Data Protection Act the Practice needs consent fromany patient that has an answerphone and is happy for us to leavea message. If we do not have consentwewillbeunable to leave a message on an answerphone or with a 3rd party.
Pleasecomplete the appropriate box:
□I do notgive consent for the Practice to leave messages on myanswerphone.
□I give consent for the Practice to leave messages on myanswerphone
Telephone no: ………………..………………… and/or …………..………………………….. (completelandline/mobile number as appropriate)
□I give consent for the Practice to leavea message about any aspect of mymedicaltreatmentwith ………………………………..
This consent is to remain in force untilfurther notice of cancellation by me.
Pleasecomplete all sections of thisform, sign and date, and return it to Reception in orderthatyour registration with the Practice canbecompleted.
As a new patient wewouldlike to offeryou the opportunity for a health check with the Health Care Assistant. Pleasemake an appointment at Reception and bring a specimen of urine whenyou attend.
SIGNED: ...... TODAY’S DATE: ......
NHS No (if known): ......
Thankyou for completingthis questionnaire
DRS IRONMONGER, WEIGHELL, HARRIS & LE ROLLAND
For office use: Namedallocated GP 9NN60
Patient notified of named GP67DJ
M:\! RECEPTION (April 2015)\New Patient Questionnaire (Adult) - Sept 2015.docx